Montrose Springs Skilled Nursing & Wellness Center
2635 Honolulu Ave, Montrose, CA 91020Map
Medicare/Medicaid certified109 certified beds~123 residents/dayFor profit - Limited Liability company
Last standard health inspection: July 3, 2025
Montrose Springs Skilled Nursing & Wellness Center is a 109-bed for-profit, LLC-owned nursing home in Montrose, Los Angeles County, California, serving an average of 123 residents per day. As of CMS data processed June 1, 2026, its overall rating is 2 of 5 stars.
CMS star ratings
CMS scores every nursing home 1–5 stars overall, built from three sub-ratings. moreless
Medicare inspects and measures every certified nursing home, then rolls the results into a 1–5 star overall rating. It combines three parts: health inspections, staffing, and quality measures. Five stars means much better than average — it does not mean perfect. One star means much worse than average — it does not mean every shift is bad. Stars are a screening tool, not a verdict. They can lag reality by months, and they can't see things like how kind the aides are or how the building smells at 7am.
What to do with this: use stars to build a shortlist, then visit in person. Nothing on this site replaces walking the halls.
Health-inspection stars are graded on a curve within each state — never compare stars across state lines. moreless
CMS sets health-inspection star cutoffs separately for each state: roughly the top 10% of homes in a state get 5 stars, the bottom 20% get 1 star, no matter how the state compares to others. That means a 4-star home in one state and a 4-star home in another state may have very different inspection records. The stars tell you how a home compares to its neighbors, not to the whole country. That's why this site shows your state's median next to each star rating — and never a national star comparison.
What to do with this: compare stars only between homes in the same state. To compare across states, use staffing hours — those are real numbers, not curves.
Not all three sub-ratings are equally hard to game: inspections are the most objective, quality measures the least. moreless
The three sub-ratings come from different sources. Health inspections are done on-site by trained state surveyors who show up mostly unannounced — the most objective signal. Staffing comes from payroll records that facilities must submit and CMS audits — quite reliable. Quality measures are partly self-reported by the facility from its own resident assessments — useful, but the facility grades some of its own homework.
What to do with this: when sub-ratings disagree, weigh the inspection star most and the quality-measure star least.
Staffing
Reported hours per resident per day, from payroll records. Hours, unlike stars, can be compared across states.
Hours per resident per day: total staff hours worked, divided by the number of residents. moreless
If a home reports 3.5 total nursing hours per resident per day, that's all nursing staff time across 24 hours — roughly one caregiver-hour every 7 hours per resident, spread across day, evening, and night shifts. On a real floor it decides whether call lights get answered in 5 minutes or 25, whether someone has time to help with dinner, and whether night shift is one aide for a hall or two. Unlike star ratings, hours are actual numbers, so they CAN be compared across state lines.
What to do with this: compare a home's hours to the state and national medians shown, and ask the facility how the hours split across day, evening, and night shifts.
RN (registered nurse) hours
This facility did not submit staffing data.
LPN (licensed practical nurse) hours
This facility did not submit staffing data.
Nurse aide hours
This facility did not submit staffing data.
Total nursing hours
This facility did not submit staffing data.
CMS also adjusts these numbers for how sick each home’s residents are — a home with sicker residents needs more staff for the same star.
CMS also adjusts staffing numbers for how sick each home's residents are. moreless
A home full of short-term rehab patients needs different staffing than a home caring for people with advanced dementia or ventilators. Case-mix adjustment estimates how many hours a home's particular residents need, then scales the reported hours so homes can be compared fairly. A home with sicker residents needs more staff for the same star. This page shows reported (raw payroll) numbers and compares them only to other reported numbers — like with like.
What to do with this: if a home's reported hours look low, check whether its residents may simply need less care — and ask the facility directly.
Staff turnover
Turnover: The facility's staffing data didn't meet the criteria for a turnover measure, so it's excluded and the staffing score is rescaled.
The share of nursing staff who left within the year. Lower is steadier. moreless
Total nursing staff turnover is the percentage of the home's nurses and aides who stopped working there during the year. Around half of nursing-home staff leaving annually is sadly common in this industry. High turnover means residents are cared for by people who don't know them — which matters enormously for dementia care, pain management, and noticing the small changes that catch problems early. Low turnover usually means staff are treated well enough to stay.
What to do with this: when you visit, ask aides how long they've worked there. Long-tenured aides are the best sign a building has.
Inspections & deficiencies
The last 3 inspection cycles, from CMS’s federal health-survey file. State-only citations and fire-safety surveys are not included — an empty list means nothing federal is in this file, not that nothing ever happened.
Each deficiency gets a letter A–L: how severe it was × how widespread it was. moreless
Surveyors grade every deficiency on a grid. Severity runs from 'potential for minimal harm' up to 'immediate jeopardy to resident health or safety.' Scope runs from isolated (one or a few residents) to pattern to widespread. A and B are paperwork-level; D–F caused no actual harm but had the potential; G–I caused actual harm; J, K, and L mean immediate jeopardy — the most serious finding a surveyor can make. Most citations nationally are D–E.
What to do with this: scan for G or higher. One J/K/L tells you more than ten D's.
Standard surveys are routine; complaint surveys happen because someone reported a problem. moreless
A standard survey is the routine top-to-bottom inspection every home gets on a recurring cycle. A complaint survey happens because a resident, family member, or staff member reported something to the state — surveyors come specifically to investigate it. Infection-control surveys focus on practices like hand hygiene and isolation procedures. A deficiency found during a complaint survey means someone cared enough to report it and a surveyor confirmed enough to cite it.
What to do with this: note which deficiencies came from complaints — they show you what residents and families actually experienced.
The F-number on each deficiency is CMS's code for which federal requirement was violated. moreless
Every federal nursing-home requirement has a tag number. F0686, for example, is the pressure-ulcer requirement; F0600 is freedom from abuse. The tag tells you exactly which rule was broken, and the description next to it is CMS's own plain-language summary of that rule. The same tag appearing across multiple inspections is a pattern worth noticing.
What to do with this: if the same tag repeats across surveys, ask the facility what changed since the last citation.
This data shows federal health surveys only — state-only citations and fire-safety surveys aren't included. moreless
CMS's public deficiency file contains federal health-survey citations. It does not include citations issued under state-only rules, fire-safety (Life Safety Code) surveys, or anything older than three inspection cycles. A facility with no rows here may still have state citations or fire-safety findings. 'No deficiencies in this file' never means 'no violations ever.'
What to do with this: for the full picture, check your state health department's site and medicare.gov/care-compare, which shows fire-safety results separately.
85 deficiencies across the last 3 inspection cycles, in CMS’s federal health-survey file:
- Quality of Life and Care: 22
- Resident Assessment and Care Planning: 17
- Resident Rights: 17
- Environmental: 8
- Pharmacy Service: 6
- Nutrition and Dietary: 5
- Freedom from Abuse, Neglect, and Exploitation: 4
- Infection Control: 3
- Nursing and Physician Services: 3
April 20, 2026Complaint surveyTag F0842D — no actual harm, potential for more than minimal harm, isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected May 8, 2026
April 7, 2026Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has no plan of correction
February 26, 2026Complaint surveyTag F0580D — no actual harm, potential for more than minimal harm, isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected March 20, 2026
February 26, 2026Complaint surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 20, 2026
February 26, 2026Complaint surveyTag F0684D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected March 20, 2026
January 22, 2026Complaint surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected February 14, 2026
January 22, 2026Complaint surveyTag F0755D — no actual harm, potential for more than minimal harm, isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected February 14, 2026
July 3, 2025Standard surveyTag F0550D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0552D — no actual harm, potential for more than minimal harm, isolated
Ensure that residents are fully informed and understand their health status, care and treatments.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0565D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to organize and participate in resident/family groups in the facility.
Deficient, Provider has date of correction · corrected July 25, 2025
Show 75 more deficiencies
July 3, 2025Standard surveyTag F0578D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0688D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard + Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0690D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0692D — no actual harm, potential for more than minimal harm, isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0745D — no actual harm, potential for more than minimal harm, isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0812E — no actual harm, potential for more than minimal harm, pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0880D — no actual harm, potential for more than minimal harm, isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0911B — no actual harm, potential for minimal harm, pattern
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0912B — no actual harm, potential for minimal harm, pattern
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Deficient, Provider has date of correction · corrected July 25, 2025
July 3, 2025Standard surveyTag F0919D — no actual harm, potential for more than minimal harm, isolated
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected July 25, 2025
May 1, 2025Complaint surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected May 22, 2025
March 28, 2025Complaint surveyTag F0600G — actual harm, isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected April 5, 2025
March 28, 2025Complaint surveyTag F0609D — no actual harm, potential for more than minimal harm, isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected April 5, 2025
March 12, 2025Complaint surveyTag F0600G — actual harm, isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected April 9, 2025
February 20, 2025Complaint surveyTag F0660D — no actual harm, potential for more than minimal harm, isolated
Plan the resident's discharge to meet the resident's goals and needs.
Deficient, Provider has date of correction · corrected March 14, 2025
July 12, 2024Standard surveyTag F0550D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0558D — no actual harm, potential for more than minimal harm, isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0580D — no actual harm, potential for more than minimal harm, isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0583D — no actual harm, potential for more than minimal harm, isolated
Keep residents' personal and medical records private and confidential.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0657D — no actual harm, potential for more than minimal harm, isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0686D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0690D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0695D — no actual harm, potential for more than minimal harm, isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0697D — no actual harm, potential for more than minimal harm, isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0730E — no actual harm, potential for more than minimal harm, pattern
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0732B — no actual harm, potential for minimal harm, pattern
Post nurse staffing information every day.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0745D — no actual harm, potential for more than minimal harm, isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0755E — no actual harm, potential for more than minimal harm, pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0759E — no actual harm, potential for more than minimal harm, pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0761E — no actual harm, potential for more than minimal harm, pattern
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0802E — no actual harm, potential for more than minimal harm, pattern
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0803E — no actual harm, potential for more than minimal harm, pattern
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0880D — no actual harm, potential for more than minimal harm, isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0911B — no actual harm, potential for minimal harm, pattern
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0912B — no actual harm, potential for minimal harm, pattern
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Deficient, Provider has date of correction · corrected August 5, 2024
July 12, 2024Standard surveyTag F0919D — no actual harm, potential for more than minimal harm, isolated
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected August 5, 2024
May 17, 2024Complaint surveyTag F0557D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Deficient, Provider has date of correction · corrected June 14, 2024
May 17, 2024Complaint surveyTag F0558D — no actual harm, potential for more than minimal harm, isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected June 14, 2024
May 10, 2024Complaint surveyTag F0635G — actual harm, isolated
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Deficient, Provider has date of correction · corrected June 3, 2024
May 10, 2024Complaint surveyTag F0711D — no actual harm, potential for more than minimal harm, isolated
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Deficient, Provider has date of correction · corrected June 3, 2024
April 9, 2024Complaint surveyTag F0558D — no actual harm, potential for more than minimal harm, isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected April 29, 2024
April 9, 2024Complaint surveyTag F0576D — no actual harm, potential for more than minimal harm, isolated
Ensure residents have reasonable access to and privacy in their use of communication methods.
Deficient, Provider has date of correction · corrected April 29, 2024
April 9, 2024Complaint surveyTag F0677D — no actual harm, potential for more than minimal harm, isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected April 29, 2024
March 6, 2024Complaint surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 22, 2024
March 6, 2024Complaint surveyTag F0684D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected March 22, 2024
February 27, 2024Complaint surveyTag F0689D — no actual harm, potential for more than minimal harm, isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected March 20, 2024
November 29, 2023Complaint surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected December 26, 2023
June 13, 2023Complaint surveyTag F0578D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Deficient, Provider has date of correction · corrected June 29, 2023
June 7, 2023Complaint surveyTag F0580D — no actual harm, potential for more than minimal harm, isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected June 15, 2023
June 7, 2023Complaint surveyTag F0610D — no actual harm, potential for more than minimal harm, isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected June 15, 2023
June 7, 2023Complaint surveyTag F0684D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected June 15, 2023
June 2, 2023Complaint surveyTag F0698D — no actual harm, potential for more than minimal harm, isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected June 28, 2023
June 2, 2023Complaint surveyTag F0745D — no actual harm, potential for more than minimal harm, isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected June 28, 2023
March 24, 2022Standard surveyTag F0557D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0584D — no actual harm, potential for more than minimal harm, isolated
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0644D — no actual harm, potential for more than minimal harm, isolated
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0655D — no actual harm, potential for more than minimal harm, isolated
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0656D — no actual harm, potential for more than minimal harm, isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0657D — no actual harm, potential for more than minimal harm, isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0658D — no actual harm, potential for more than minimal harm, isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0686D — no actual harm, potential for more than minimal harm, isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0693D — no actual harm, potential for more than minimal harm, isolated
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0695D — no actual harm, potential for more than minimal harm, isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0698D — no actual harm, potential for more than minimal harm, isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0755D — no actual harm, potential for more than minimal harm, isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0759D — no actual harm, potential for more than minimal harm, isolated
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0803E — no actual harm, potential for more than minimal harm, pattern
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0812D — no actual harm, potential for more than minimal harm, isolated
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0842D — no actual harm, potential for more than minimal harm, isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0881D — no actual harm, potential for more than minimal harm, isolated
Implement a program that monitors antibiotic use.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0911B — no actual harm, potential for minimal harm, pattern
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Deficient, Provider has date of correction · corrected April 26, 2022
March 24, 2022Standard surveyTag F0912B — no actual harm, potential for minimal harm, pattern
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Deficient, Provider has date of correction · corrected April 26, 2022
Fines & penalties
CMS can fine a home or stop paying for new admissions. Shown per CMS's current data window (~3 years) — not all-time. moreless
When deficiencies are serious or aren't fixed, CMS can impose a fine (a civil money penalty) or a payment denial — refusing to pay for new Medicare/Medicaid admissions until the home fixes the problem. Payment denials hit harder than most fines because they stop revenue. CMS's public dataset covers a rolling window of roughly the last three years, so the totals here are recent history, not an all-time record. Many facilities have no penalties in the window — that's common, not remarkable.
What to do with this: a recent large fine deserves a direct question on your visit — what happened, and what changed?
Fines: 1 totaling $32,139 · Payment denials: 1 — per CMS data (rolling ~3-year window).
| Date | Type | Amount / length |
|---|---|---|
| February 20, 2025 | Fine | $32,139 |
| May 10, 2024 | Payment Denial | 6 days, from June 8, 2024 |
Ownership & chain
Who actually owns and controls the facility — individuals, companies, and their stakes. moreless
Nursing homes are often owned through layers: an operating company, a property company, management companies, and individual investors with percentage stakes. CMS publishes who holds 5%-or-greater interests and who has operational control. Ownership matters because it sets the budget: research has linked some ownership structures, especially certain chains and investment vehicles, to lower staffing. That's a pattern across the industry, not a verdict on any one building.
What to do with this: know who owns the home before you sign anything, and ask the administrator who actually sets the staffing budget.
Part of Pacific Healthcare Holdings (15 facilities). Chain average overall rating: 1.9★ — this facility: 2★.
Most US nursing homes belong to a chain. The chain's average rating is context for this home's rating. moreless
A chain is a group of facilities sharing an owner or operator. Chains share budgets, policies, and management practices, so a chain's average rating tells you something about the company behind the building. A home rating well above its chain's average may have an unusually strong local team; one below it may be the chain's neglected building. Either way, the chain sets the constraints the local staff work within.
What to do with this: if the chain average is low, ask the administrator what this building does differently.
| Owner / manager | Role | Stake | Since |
|---|---|---|---|
| Pacific Healthcare Holdings, Inc. (Organization) | 5% or greater direct ownership interest | 88% | 08/31/2007 |
| Aghajanyan, Ani (Individual) | Adp of the snf | NOT APPLICABLE | 06/12/2017 |
| Corporate Interface Services LLC (Organization) | Adp of the snf | NOT APPLICABLE | 04/10/2025 |
| Karakashian, Garo (Individual) | Adp of the snf | NOT APPLICABLE | 02/01/2017 |
| Rechnitz, Shlomo (Individual) | Adp of the snf | NOT APPLICABLE | 08/31/2007 |
| Rockport Administrative Services, LLC (Organization) | Adp of the snf | NOT APPLICABLE | 04/10/2025 |
| Rechnitz, Shlomo (Individual) | Corporate officer | NOT APPLICABLE | 08/31/2007 |
| Aghajanyan, Ani (Individual) | Operational/managerial control | NOT APPLICABLE | 06/12/2017 |
| Corporate Interface Services LLC (Organization) | Operational/managerial control | NOT APPLICABLE | 03/18/2024 |
| Karakashian, Garo (Individual) | Operational/managerial control | NOT APPLICABLE | 02/01/2017 |
| Rechnitz, Shlomo (Individual) | Operational/managerial control | NOT APPLICABLE | 08/31/2007 |
| Rockport Administrative Services, LLC (Organization) | Operational/managerial control | NOT APPLICABLE | 01/15/2008 |
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Most families compare 2–3 homes. Same county, sorted by overall rating:
Visiting? Go in with questions.
Built from this facility’s own CMS data — bring them on the tour.
- CMS shows this facility did not submit staffing data — ask to see current staffing schedules for the unit your person would live on.
- CMS data shows 1 fine totaling $32,139 in its current data window — ask what the citations were for and what changed afterward.
- Their last standard health inspection was July 3, 2025 — ask what's improved since then.
- CMS records that this facility has a resident and family council — ask to speak with a council member before deciding.
- They have 109 certified beds and serve an average of 123 residents per day — ask which unit your person would be on and who staffs it overnight.
- CMS lists this facility as part of PACIFIC HEALTHCARE HOLDINGS (15 facilities) — ask what the chain decides centrally and what this building's team controls.
Data: Centers for Medicare & Medicaid Services (data.cms.gov), processing date June 1, 2026. This site is not affiliated with CMS or any government agency.